Review a payer contract change

A new payer proposal may change more than the headline rate. Start with the relevant agreement, identify the terms that change and compare both versions against the services your organization provides.

Use this page to prepare the comparison, then follow the contract review guide for the detailed checks.

Start with the agreement you actually have

Keep the agreement, amendments, applicable fee schedules, and any documents incorporated into it together. Make a note of which version you are using and when it applies. A comparison can be internally consistent and still use the wrong starting terms.

Use your organization’s approved records rather than a general article to establish the rate. A public Medicare reference may help you understand a benchmark; it does not, on its own, establish a commercial payer’s obligation.

For a first pass, write a short description of the scope: payer product, provider group, location, services, and period. If you cannot establish one of those, mark it as a question rather than filling in an assumption that nobody has checked.

Compare more than the headline percentage

In the DueMD scenario, two terms change together: the base multiplier and the percentage paid for a second procedure. Raising one and lowering the other can produce a lower overall total. That is an illustration of why a single percentage is not a complete comparison—not a statement about any specific payer.

List the terms you know are changing. Then separate terms you can model from terms that require a closer reading. A special rate for a service, for example, should not quietly become a general adjustment for every case.

Keep the volume and mix identical when your question is about the effect of the terms. A separate forecast can explore changing activity, but it answers a different question.

Try one change at a time

Open the Contract Amendment Impact Calculator and load the example. It uses 10,000 cases, a $100 primary reference, and one $80 second procedure in 40% of cases.

Under the current terms, the base multiplier is 100% and the second-procedure payment is 75%. Under the proposed terms, those figures are 106% and 50%. The total falls from $1,240,000 to $1,229,600: a decrease of $10,400.

Now restore the second-procedure percentage to 75%. This isolates the base-rate change. The exercise helps you explain which assumption drives the result, rather than relying on the total alone.

This example holds volume and service mix constant to isolate the two payment terms. Its $100 and $80 references are illustrative; modifier and eligibility rules are outside the calculator’s scope.

Make the reference explicit

If your agreement uses a percentage of Medicare, establish which reference it means before doing the multiplication. Record the fee schedule, version, setting, and any other inputs required by that agreement. Do not assume the newest file is necessarily the contracted one.

CMS publishes Physician Fee Schedule reference files. DueMD’s Medicare reference lookup uses an imported snapshot for the dates and settings shown in the tool. The contract impact calculator is separate: it applies the reference amounts you enter.

Our answer on what “110% of Medicare” tells you explains the difference between a percentage and a complete pricing instruction.

If you send the comparison to someone else, include the original assumptions rather than only a screenshot of the total. That makes a question about a rate or second-procedure factor much easier to resolve without rebuilding the analysis from memory.

Turn uncertainty into a review list

Before sharing a scenario, check the source of the current terms, the proposed effective date, and whether both scenarios cover the same activity. Mark anything that the simple model leaves out. Keep these notes with the result so someone else can reproduce the comparison.

A useful handoff says, “Using these assumptions, this term accounts for this change.” It does not say, “This is what every future claim will pay.” If a provision is unclear or disputed, take it to the person responsible for contract interpretation in your organization.

Begin with the worked amendment guide. For a shorter checklist, use the payer contract review page.